Membrane-associated diseases, those diseases and disorders whose pathology is directly linked a specific membrane or subset of membranes, have increased in incidence over time. Numerous and varied diseases falling into this category exist (see, “The Merck Manual of Diagnosis and Therapy, 17th Ed.”, Berkow, R., et al., Eds., John Wiley & Sons, 1999), but can generally be broken into broader categories, such as inflammatory diseases, ciliary dyskinesias, and platelet aggregation disorders. Concomitant with the numerous types of diseases and disorders falling into this category, numerous approaches to the therapeutic treatment or prevention of these disorders have appeared.
Inflammatory diseases, encompassing arthritis, represent one of the largest categories of membrane-associated diseases. Research spanning the last decade has helped to elucidate the molecular events associated with membrane-associated diseases in the body, especially those events involved in the movement and activation of cells in the immune system. See, generally, Springer, T. Nature, 346: pp. 425-434 (1990). Cell surface proteins, and especially the Cellular Adhesion Molecules (“CAMs”) and “Leukointegrins”, including LFA-1, MAC-1 and gp150.95 (referred to in WHO nomenclature as CD18/CD11a, CD18/CD11b, and CD18/CD11c, respectively) have correspondingly been the subject of pharmaceutical research and development having as its goal the intervention in the processes of leukocyte extravasation to sites of injury and leukocyte movement to distinct targets. For example, it is presently believed that prior to the leukocyte extravasation, which is a mandatory component of the inflammatory response, activation of integrins constitutively expressed on leukocytes occurs and is followed by a tight ligand/receptor interaction between integrins (e.g., LFA-1) and one or several distinct intercellular adhesion molecules (ICAMs) designated ICAM-1, ICAM-2, ICAM-3 or ICAM-4 which are expressed on blood vessel endothelial cell surfaces and on other leukocytes. The interaction of the CAMs with the Leukointegrins is a vital step in the normal functioning of the immune system. Immune processes such as antigen presentation, T-cell mediated cytotoxicity and leukocyte extravasation all require cellular adhesion mediated by ICAMs interacting with the Leukointegrins. See generally, Kishimoto, T. K.; Rothlein; R. R. Adv. Pharmacol. 25: 117-138 (1994) and Diamond, M.; Springer, T., Current Biology, 4: 506-532 (1994). As a result, a wide variety of anti-inflammatory based compounds have been contemplated as therapeutic agents.
Several small molecules have been described in the literature which are potentially useful in the treatment of membrane-associated disorders related to inflammation. A natural product isolated from the root of Trichilia rubra was found to be inhibitory in an in vitro cell binding assay (Musza, L. L.; et al., Tetrahedron, 1994, 50, 11369-11378). One series of molecules (Boschelli, D. H.; et al., J. Med. Chem, 1994, 37, 717 and Boschelli, D. H.; et al., J. Med. Chem. 1995, 38, 4597-4614) was found to be orally active in a reverse passive Arthus reaction, an induced model of inflammation that is characterized by neutrophil accumulation (Chang, Y. H.; et al, Eur. J Pharmacol. 1992, 69, 155-164). Another series of molecules was also found to be orally active in a delayed type hypersensitivity reaction in rats (Sanfilippo, P. J.; et al., J. Med. Chem. 1995, 38, 1057-1059).
Numerous other classes of compounds have been described in the patent literature as having the potential to alleviate membrane-associated diseases and disorders, including aerosolized antibiotics (U.S. Pat. No. 6,387,886); uridine triphosphate and related compounds (U.S. Pat. No. 6,159,952); 1H-indole-3-glyoxylamide (U.S. Pat. No. 5,972,988); and a method for the treatment of otitis media and paranasal sinusitis using human defensins, lysozyme and/or lactoferrin as a new class of non-antibiotic antimicrobials (U.S. Pat. No. 6,716,813). U.S. Pat. No. 6,423,721 describes antibiotic-excluded compositions and methods to treat non-infective sinusitis and/or otitis media. The compositions contain a therapeutically effective amount of an anticholinergic antihistamine or a pharmaceutically acceptable salt or solvate thereof; and a pharmaceutically acceptable carrier, as well as methods of administering the same. Additionally, benzimidazoles have been suggested for use in the treatment of conjunctivitis, especially allergic conjunctivitis (U.S. Pat. No. 5,641,781).
Another membrane-associated disease whose incidence has recently increased is oral-membrane disease/disorder xerostomia. Xerostomia occurs when inadequate amounts of saliva are secreted into the mouth, preventing adequate lubrication of the oral cavity and resulting in an uncomfortable oral sensation and difficulty with speaking and swallowing, and in some instances severe cracking of the tongue.
Xerostomia can result from either decreased production of saliva within the glands and/or diminished secretion of saliva from the glands following autonomic stimulation. It is most commonly caused as an unwanted side effect of many classes of prescription medications including anticholinergics, antispasmodics, antihypertensives, antidepressants, anticonvulsants, pain killers, anti-rejection drugs, and antipsychotics, as well as over-the-counter decongestants and antihistamines (Brown, C. G., et al., Semin Oncol Nurs., 20: pp. 16-21 (2004)). These classes of drugs either directly inhibit saliva production within the glands or inhibit its secretion into the mouth by inhibiting the autonomic nervous system (Friedlander, A. H., et al., Oral Surg Oral Med Oral Pathol Oral Radiol Endod., 94: pp. 404-416 (2002)). Xerostomia can also occur during states of elevated stress, anxiety, depression, with certain endocrine diseases such as hypothyroidism, during chemotherapy, and with auto-immune disorders such as Sjögren's syndrome. Furthermore, the glands can be destroyed by radiation therapy to the neck, traumatic injury to the neck, neck surgery, or by other direct injury of the gland and its controlling autonomic nerves. The incidence of xerostomia also increases in the elderly (Locker, D., Spec Care Dentist., 23: pp. 86-93 (2003)).
Adequate salivary gland function is critical for protection of the oral cavity and support of oral functions, including speech and oral comfort. In humans saliva is provided by the three paired major salivary glands, (parotid, submandibular and sublingual), and thousands of minor salivary glands which are situated throughout the oral cavity and named based on location (buccal, palatal, labial, etc.). Between meals salivary flow is maintained at a low level of output by endogenous physiologic mechanisms. The unstimulated, or resting, saliva is essential for general oral comfort and is high in antimicrobial and mucoprotective factors. The salivary glands are activated by masticatory and gustatory stimuli during meals, resulting in a marked increase in salivary output. This stimulated output provides support for swallowing, chewing and buffering of microbial acids, but the output quickly falls to the resting level once active stimulation ceases.
In the absence of saliva, oral bacterial effects accelerate. Users of medications that cause xerostomia have been reported to have 10 times the normal level of oral bacteria, and three to four times the normal level of dental decay (study presented at the International Association of Dental Research, Nice, France, 1998). Patients with dry mouth are also more prone to fungal infections, gum disease and (due to xerostomic discomfort in eating some types of foods) malnutrition.
Typical treatments for xerostomia have involved supportive and replacement therapies to restore oral moisture, as well as pharmacologic agents to stimulate the body's own saliva production. Examples of such treatments have included the use of carbamide peroxide (U.S. Pat. No. 6,200,551), pilocarpine (Hendrickson, et. al., J Emerg Med., 26: pp. 429-432 (2004); U.S. Pat. No. 4,209,505), a combination of algae and pectin in a lozenge (U.S. Pat. No. 6,027,715), regular parenteral treatment with interferon-α (Ferraccioli et al.), and the administration of lozenges containing maltose or trehalose (U.S. Pat. No. 6,656,920). Several secretogogues with transient benefits have failed to demonstrate sustained benefit in controlled clinical trials; these include bromhexine, anetholetrithione, pilocarpine, and cevimeline. Side effects have included excessive sweating during treatment with pilocarpine or cevimeline.
A further category of membrane-associated disorders is primary ciliary dyskinesias. Primary ciliary dyskinesia (PCD) is a congenital disease characterized by ultrastructural defects and motility disturbances of cilia, resulting in either absent or abnormal ciliary movement. The most common clinical manifestations of PCD are chronic respiratory disease (e.g., sinusitis, rhinitis, and bronchiectasis) and otitis media. Because PCD patients have either no or severely impaired mucociliary clearance (MCC), the only available mechanism to clear or move secretions is cough. PCD has also been reported to impair the propulsion of spermatozoa, resulting in male infertility. (D. Schidlow, Ann Alergy, 73(b): pp. 457-68 (1995)). Typical methods of treating this membrane-associated disorder include administering uridine triphosphates, adenosine triphosphates, cytidine triphosphates, or dinucleoside tetraphosphates and their derivatives thereof to a patient so as to treat this dysfunction of the mucociliary clearance system (see, for example, U.S. Pat. No. 6,673,779). Uridines, especially di(uridine 5′)-tetraphosphate (U.S. Pat. Nos. 6,548,658 and 6,713,458) and analogs of both this compound and uridine triphosphate (U.S. Pat. No. 5,968,913; U.S. Pat. No. 6,451,288) have also been suggested for use in controlling membrane-associated diseases such as primary ciliary dyskinesia.
Mucociliary clearance is an important defense mechanism of the human airway and middle/inner ear tract. Coordinated beats of cilia in the nose, trachea, bronchi, and middle ear propel the mucous layer toward the pharynx, carrying along with it microorganisms and other particles captured in the mucus. Normal function of this system depends on the frequency and coordination of ciliary beating and the properties of mucus. There are three components of the mucociliary clearance system: (1) the mucin layer, which is formed by secretion of mucins by goblet cells, (2) cilia, which transport the overlying mucin layer by synchronous beating, and (3) the periciliary liquid layer, which surrounds the cilia and is less viscous than the mucin layer, allowing free movement of the cilia. The electrolyte and water concentration of the periciliary layer is regulated by the luminal epithelial cells. (R. Boucher, et al., Adenosine and Adenine Nudeotides: From Molecular Biology to Integrative Physiology, p. 525-32 entitled “Mechanisms and Therapeutic Actions of Uridine. Triphosphates in the Lung” (L. Belardinelli, et al. ed., Alumwer Academic Publishers, Boston 1995)).
PCD also results in the impairment of cell motility of certain immune system cells, including neutrophils and macrophages. (N. Valerius, Eur J Clin Invest 13, 489-94 (1983)). PCD can be responsible for a form of hydrocephalus caused by ciliary malfunction. (M. Greenstone, Arch Dis Child 59,481-82 (1984)). The incidence of PCD has been calculated to be one in 16,000 live births, and an estimated 50% of affected individuals also have situs inversus (dextrocardia). The triad of bronchiectasis, sinusitis, and situs inversus (dextrocardia) is referred to as Kartageneis syndrome. (M. Sleigh, Lancet ii, 476 (1981)). It has been hypothesized that Kartagener's syndrome is caused by a lack of embryonic ciliary movement, resulting in the random rotation of the archenteron such that in half the cases there is situs inversus (dextrocardia) and in the other half there is normal cardia situs. (B. Afzelius, Science 193, 317-19 (1976)). The clinical course of PCD is characterized primarily by sinus and ear infections early in life with a progressive change to lung/lower airways diseases in adulthood. Chronic airways infections can lead to chronic obstructive changes in the pulmonary tissue, progressive loss of pulmonary function, and eventually death.
A second and more common form of ciliary dyskinesia is the acquired form of the disease. Chronic inflammation caused by severe viral or bacterial respiratory infections, chronic smoking, severe air pollution, chemical or thermal bums to the airways, intubation and mechanical ventilation, and near-drowning can result in changes in ciliary structure including disruption of the cellular membrane, loss or incorporation of microtubules, and formation of compound cilia, all of which can result in abnormal or absent ciliary function. (J. Ballenger Ann Otol Rhinol Laryngol 97 (3 Pt. 1), 253-58 (1988); U Pedersen Lung 168 Suppl., 368-76 (1990)). Respiratory infections which often lead to secondary ciliary dyskinesia include influenza, adult respiratory distress syndrome, and ventilator-associated pneumonia (VAP) in intensive care unit (ICU) patients. In some cases acquired ciliary dyskinesia can be reversed with appropriate and timely intervention; however, permanent damage and/or sustained exposure to the above factors can render the ciliary damage irreversible. The clinical manifestations and course would likely appear similar to PCD with respect to chronic lung infections, progressive loss of pulmonary function, and obstructive pulmonary disease.
The typical mammalian respiratory epithelial ceil contains about 200 cilia. Each cilium has nine peripheral microtubular doublets and two central tubules. Each peripheral doublet contains an A subunit and a B subunit, and each A subunit has a set of curved arms attached to it called the inner and outer dynein arms. These dynein arms contain ATPase-an enzyme which breaks down adenosine triphosphate (ATP), providing the energy for ciliary movement. Because the most common ultrastructural abnormality associated with primary ciliary dyskinesia is the total absence of dynein arms (B. Afzelius, et al, J Cell Biol 66, 225-32 (1975)), researchers began investigating whether extracellular application of ATP and ATPase could activate immotile cilia in vitro. (J. Forrest, et al., Am Rev Resp Dis 120, 511-15 (1979)). Although the results appeared positive, the findings have not been consistently reproduced by others. It was later discovered that extracellular application of Ca2+ and cAMP could increase the beat frequency of respiratory tract cilia. (A. Lansley, et al., Am J. Physiol 263, L232-42) (1992)). It has not been definitively established that any therapy can stimulate cilia beat in cases where complete ciliary immotility has been demonstrated. In such cases, it can be of therapeutic benefit to increase hydration of the viscous mucous secretions.
It is known that ATP/UTP stimulates ciliary beat frequency in nasal epithelial cells (R. Boucher, et al., supra); UTP stimulates mucin secretion by goblet cells (M. Lethem, et al., Am J Respir CeI Mol Biol 9, 315-22 (1993)); and UTP stimulates C1 secretion in airway epithelial cells, which increases hydration of the periciliary liquid layer (M. Knowles, et al., N Eng J. Med 325, 533-38 (1991)).
There is an ongoing need in the art for improved therapeutic means to promote clearance of secretions from the sinuses, upper airways, ears, urinary tract, spermatozoa, ovaries, fallopian tubes, neutrophils, and macrophages of a patient.
Another area of interest in the area of membrane-associated diseases and disorders are platelet aggregation disorders, such as fibrinogen-dependent platelet aggregation, thrombin-induced platelet aggregation, and collagen-induced platelet aggregation. The basic mechanism of platelet aggregation has been well-studied. The mechanism starts with a blood vessel injury such as narrowing of the lumen, plaque formation, and the presence of foreign bodies/medical instruments. This injury leads to platelet activation and binding of fibrinogen and ligands. Upon ligand binding, the JAK (Janus-family Kinase) kinases, a family of cytoplasmic protein tyrosine kinases which mediate cytokine receptor signaling, undergo tyrosine phosphorylation and activate the cytoplasmic latent forms of the STAT family transcription factors (Signal Transducers and Activators of Transcription). This activity is mediated by a number of platelet adhesive glycoproteins. The binding sites for fibrinogen, fibronectin and other clotting factors have been located on the platelet membrane glycoprotein complex IIb/IIIa. When a platelet is activated by an agonist such as thrombin, the GPIIb/IIIa binding site becomes available to fibrinogen, eventually resulting in platelet aggregation and clot formation. Diseases involving platelet aggregating disorders include the following.
Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of death in most industrial countries. This disease involves large, medium and small arteries throughout the body. In addition to family history, the atherogenic risk factors are known to include smoking, hypertension, diabetes mellitus, cholesterol abnormalities and homocysteinuria. The presence of each additional risk factor markedly aggravates the potential for development of the disease. Although seemingly diverse, the risk factors all damage the artery wall and effect formation of thrombosis.
In the aorta, the largest artery, the artery wall damage can lead to aortic aneurysm or embolism. ASCVD in medium and small arteries can result in sudden occlusion of the vessel or progressive narrowing of the arterial lumen. The symptoms of persons with this disease are dictated by the organs supplied by the effected arteries. Lumenal narrowing of the arteries supplying the heart with blood is called coronary artery disease (CAD). The symptoms include angina, unstable angina, myocardial infarction (MI) and sudden death. Cerebral vascular disease (CVD) symptoms include progressive neural deterioration, transient ischemic attack (TIA), seizures, and cerebral vascular accident (CVA), i.e., stroke. Kidney effects include hypertension, renal infarction and renal failure. Abdominal vascular insufficiency results in abdominal angina and bowel infarction. Peripheral vascular disease (PVD) symptoms include intermittent claudication, gangrene and amputation.
Because atherosclerosis greatly increases the risk of peripheral vascular disease, angina, stroke, some causes of neural degeneration, and heart attacks—the number one cause of death in the USA, a comprehensive approach is needed to address this problem. Despite the broad use of lipid lowering agents, individuals with elevated homocysteine levels are about four times more likely to die of cardiovascular disease than those with normal levels.
Currently accepted clinical treatment of ASCVD includes prescription medications such as beta blockers, angiotensin converting enzyme (ACE) inhibitors, calcium channel blockers, and cholesterol lowering medication. In addition, aspirin is prescribed by cardiologists in many ASCVD conditions. For example, in atherosclerotic heart disease (ASHD), there is evidence of protection from a second MI, if aspirin is used after the sentinel event. Risk of MI is decreased by approximately 50 percent. Vitamins are also currently prescribed by many cardiologists and endocrinologists with intent of preventing both primary (first event), and secondary events.
Many therapeutic approaches have attempted to control platelet aggregation and the resulting membrane-associated diseases by blocking various formation sites, and/or the glycoprotein complex itself. U.S. Pat. No. 6,136,794 describes the use of low molecular weight heparin in combination with a GPIIb/IIa antagonist in order to inhibit platelet aggregation; U.S. Pat. Nos. 6,291,469 and 6,693,109 describe the use of a variety of spiro compounds as inhibitors of fibrinogen-dependent platelet aggregation; creatine kinase inhibitors have also been suggested for use as inhibitors of platelet aggregation (U.S. Pat. No. 6,444,695), as have urea derivatives (U.S. Pat. No. 6,268,380) and flavonoids (U.S. Pat. No. 6,221,357).
Several other compositions, including uridine triphosphate and tetraphosphate, as well as salts thereof (U.S. Pat. No. 6,319,908; EP 1253916A1) and dinucleotide polyphosphate compositions have been described for use in treating vaginal dryness and promoting vaginal secretions (U.S. Pat. No. 6,448,276; U.S. Pat. No. 6,462,028), inhibiting platelet aggregation, treatment of lung diseases (WO 9909998A1), treating ciliary dyskinesia (U.S. Pat. No. 6,420,347), inhibiting platelet aggregation (WO 0216381A3), modulating mucociliary clearance and ciliary beat frequency (U.S. Pat. No. 6,348,589), promoting mucosal hydration (U.S. Pat. No. 6,331,529), and treating bronchitis (U.S. Pat. No. 6,159,952).
All of these molecules, while largely specific to particular membrane-associated diseases, appear to act nonspecifically, or suffer from delivery problems due to poor absorption properties of the compounds. Thus they have shortcomings in potency, selectivity, solubility, and specificity of mechanism, and are unlikely to be satisfactory for therapeutic use.
Thus, based upon the limited success of other chemotherapeutic approaches to membrane-associated diseases to date, there is a need for pharmaceuticals that are suitable for use in the treatment of a variety of membrane-associated diseases and disorders.
It is an object of the present invention to provide improved methods for the treatment of a variety of membrane-associated diseases and disorders.
It is another object of the present invention to provide compositions and formulations for the treatment of membrane-associated diseases and disorders.